Chapter 8,9,10 *911*

10. The 125-pound nurse assesses the weight of a patient. What weight is the heaviest the nurse may safely lift by herself? a. 158.75 lb b. 168.75 lb c. 178.75 lb d. 188.75 lb

ANS: B Nurses should never attempt to lift more than 35% above their own body weight. 125 0.35 = 43.75 125 + 43.75 = 168.75 PTS: 1 DIF: Cognitive Level: Analysis REF: Page 182 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation

26. The nurse is assisting a patient to perform personal hygiene. What is the most important focus of the nurse when assisting this patient? a. Nursing care b. Independence c. Repetition d. Performance

ANS: B The nurse should encourage the patient's independence as much as possible. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 185 OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Implementation

20. The most common cause of musculoskeletal disorders in nurses involves a movement that requires the nurse to and at the same time.

ANS: twist, lift lift, twist The motion of twisting and lifting at the same time frequently strains the muscles of the lower back. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 162 OBJ: 1 | 2 TOP: Muscle strain KEY: Nursing Process Step: N/A

19. The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient? (Select all that apply.) a. Pupils b. Pain c. Sensation d. Color e. Skin temperature

ANS: B, C, D, E One of the responsibilities of the nurse is to frequently monitor the patient's neurovascular function, or circulation, movement, and sensation (CMS) assessment. The LPN/LVN checks for skin color, temperature, movement, sensation, pulses, capillary refill, and pain. Pupil assessment is part of a neurologic assessment. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 166 OBJ: 8 | 13 TOP: Neurovascular function KEY: Nursing Process Step: Assessment

14. The nurse is performing passive range-of-motion exercises on a patient following a traumatic injury. What is the number of times the nurse should move each joint when performing passive range-of-motion (ROM) exercises? a. Three b. Four c. Five d. Six

ANS: C Each movement should be repeated five times. PTS: 1 DIF: Cognitive Level: Application REF: Page 173 Skill 8-2 OBJ: 6 TOP: Range of motion (ROM) KEY: Nursing Process Step: Implementation

10. The nurse attempts to avoid a pressure ulcer for a bedridden patient by turning the patient frequently. What is the most favorable position for the nurse to move this patient into? a. Back-lying b. Full lateral c. 30-degree lateral d. Full prone

ANS: C It is preferable to use the 30-degree lateral incline position. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5 OBJ: 5 TOP: Pressure ulcers KEY: Nursing Process Step: Implementation

6. The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient? a. The need for additional calcium b. The need for additional protein c. The need for some type of exercise d. The need for a special protective bed

ANS: C The immobilized patient must receive some type of exercise to prevent atrophy and contractures. PTS: 1 DIF: Cognitive Level: Application REF: Page 169 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation

29. Where should a nurse performing a backrub begin? a. Shoulder b. Base of the neck c. Sacral area d. Lumbar area

ANS: C The nurse should begin a massage in the sacral area. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 199 Skill 9-1 OBJ: 7 TOP: Hygiene KEY: Nursing Process Step: Implementation

4. Where should the nurse place the load when carrying heavy objects? a. In a low position b. To the side of the body c. Close to the body midline d. With another's assistance

ANS: C The nurse should carry objects close to the midline of the body. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 162 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation

3. What should the nurse do to protect his or her back when lifting or moving a patient? a. Lowering the height of the bed b. Holding the back straight with locked knees c. Bending knees and hips d. Getting the patient to the side of the bed

ANS: C The nurse's back can be well protected when he or she bends knees and hips. PTS: 1 DIF: Cognitive Level: Application REF: Page 161 OBJ: 11 TOP: Body mechanics KEY: Nursing Process Step: Implementation

32. The physician orders a patient to be placed in the reverse Trendelenburg position. How should the nurse place the bed? a. On the floor b. Parallel with the floor c. Tilted with the head of the bed down d. Tilted with the foot of the bed down

ANS: D The entire bed is tilted downward with the foot of the bed down when placing a patient in the reverse Trendelenburg position. PTS: 1 DIF: Cognitive Level: Application REF: Page 189 Table 9-1 OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation

19. Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes? a. Upward toward the forehead b. Downward toward the chin c. From the outer toward the inner canthus d. From the inner toward the outer canthus

ANS: D The eye is cleansed from the inner to outer canthus. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 213 OBJ: 6 TOP: Eye care KEY: Nursing Process Step: Implementation

12. How will the nurse correctly replace a patient's dentures after cleaning? a. Inserting the lower denture first b. Asking the patient to insert them c. Inserting both dentures together d. Inserting the upper denture first

ANS: D When reinserting dentures, replace the upper dentures first. PTS: 1 DIF: Cognitive Level: Application REF: Page 206 Skill 9-2 OBJ: 6 TOP: Oral hygiene KEY: Nursing Process Step: Implementation

9. The nursing assessment of a pressure ulcer includes size, depth, pain, odor, and color of tissue. What does this evaluate? a. Treatment needed b. Effectiveness of implementation c. Whether improvement is occurring d. Need for additional interventions

ANS: C Ongoing assessment of a pressure ulcer will evaluate whether improvement is occurring. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 201 OBJ: 5 TOP: Pressure ulcers KEY: Nursing Process Step: Assessment

7. What is the term for range of motion (ROM) when it is performed by the patient? a. Assisted b. Passive c. Active d. Coordinated

ANS: C ROM performed actively by the patient is designated as active ROM. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 169 OBJ: 9 TOP: Range of motion (ROM) KEY: Nursing Process Step: Implementation

13. Proper hair care is important for the patient's self-image. What is the proper water temperature when shampooing a patient's hair? a. 101° F b. 105° F c. 110° F d. 120° F

ANS: C Water at 110° F should be used to shampoo a patient's hair. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 208 Skill 9-3 OBJ: 6 TOP: Hair care KEY: Nursing Process Step: Implementation

36. Because of its effect on epithelization, the LPN/LVN should confirm the order to use or on a stage III pressure ulcer.

ANS: peroxide, alcohol alcohol, peroxide Peroxide and alcohol have a negative effect on epithelization of a pressure ulcer. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 202 Box 9-5 OBJ: 5 TOP: Pressure ulcers KEY: Nursing Process Step: Implementation

18. The nurse explains that the measurement of radiation exposure is in multiples of Gy. The number of Gy an individual may absorb before becoming ill with radiation syndrome is .

ANS: 0.75 The amount of radiation absorbed is measured by the Gy. 1 Gy is equal to 100 rad. Absorption of 0.75 Gy will cause the individual to develop acute radiation syndrome. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 248 OBJ: 11 TOP: Radiation syndrome KEY: Nursing Process Step: Implementation

24. The nurse points to the X in the illustration below and describes this point as the of .

ANS: center, gravity The center of gravity is the centermost point from the base of support. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 161 OBJ: 2 TOP: Center of gravity KEY: Nursing Process Step: Implementation

5. The nurse is assessing a patient's skin for signs of impaired skin integrity. Which finding by the nurse is considered a major manifestation? a. Burn b. Laceration c. Pressure ulcer d. Infection

ANS: C A major manifestation of impaired skin integrity is a pressure ulcer. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 5 TOP: Pressure ulcers KEY: Nursing Process Step: Assessment

23. machines flex and extend joints to mobilize them passively without the strain of active exercises.

ANS: Continuous passive motion (CPM) Continuous passive motion CPM Continuous passive motion (CPM) machines flex and extend joints to mobilize them passively without the strain of active exercises. It is imperative that the CPM machine be set according to the health care provider's orders for the degree and the speed of flexion and extension for each individual patient to prevent damage to the joint or surgical site. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 172 OBJ: 12 TOP: Continuous passive motion machines KEY: Nursing Process Step: Implementation

16. When reinforcing the PASS acronym for fire extinguisher use, the nurse reminds the staff that the final "S" stands for _ .

ANS: sweep The acronym stands for: P = pull pin, A = aim, S = squeeze, S = sweep. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 241, 243 Box 10-10 OBJ: 7 TOP: Fire extinguisher use KEY: Nursing Process Step: Implementation

38. As a safety precaution against breakage of dentures, the nurse should place in the emesis basin before cleaning the dentures.

ANS: water Water in the basin will break the fall of the dentures if they are dropped. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 206 Skill 9-2 OBJ: 6 TOP: Oral hygiene KEY: Nursing Process Step: Implementation

8. The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM? a. The fullest extent b. Place the joint in normal position c. The point of pain d. Relax the patient

ANS: C The joints are moved to the point of resistance or pain. PTS: 1 DIF: Cognitive Level: Application REF: Pages 173 OBJ: 9 TOP: Range of motion (ROM) KEY: Nursing Process Step: Implementation

21. To maintain a wide base of support, the nurse should stand with the feet separated by the distance of times the length of the nurse's shoe.

ANS: 1.5 one and one half A wide base of support of 1.5 times the length of the nurse's shoe is recommended. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 161 OBJ: 1 TOP: Base of support KEY: Nursing Process Step: Implementation

17. The nurse conducting a seminar on bioterrorism reviews several types of agents that may be used as weapons. An agent that does not seriously damage or kill the target population but only impairs it is classified as .

ANS: incapacitating The agent that only impairs the target rather than killing or seriously damaging it is classified as an incapacitating agent. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 246-249 OBJ: 11 TOP: Bioterrorism KEY: Nursing Process Step: Implementation

2. What is important for the nurse to determine in order to decrease the risk for injury to a patient? a. If patient can read English b. If patient is left-handed c. If patient is able to eat unassisted d. If patient can dress independently

ANS: B A left-handed patient will twist to accommodate, which places them at risk for injury. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 229-230 OBJ: 1 TOP: Safety KEY: Nursing Process Step: Assessment

8. The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus ulcer? a. I b. II c. III d. IV

ANS: B A pressure ulcer demonstrating blisters is a stage II decubitus ulcer. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 OBJ: 5 TOP: Pressure ulcers KEY: Nursing Process Step: Assessment

1. The nurse manager is providing an in-service regarding a "safe hospital environment." What will this education mainly focus on preventing? a. Falls b. Exposure to contaminants c. Injury d. Electrical hazard

ANS: C A safe environment implies freedom from injury. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 228 OBJ: 6 TOP: Safety KEY: Nursing Process Step: Implementation

7. What type of fire extinguisher should the nurse use when the oxygen concentrator machine malfunctions and causes an electrical fire? a. Type A b. Type B c. Type C d. Type D

ANS: C Electrical fires require type C fire extinguishers. PTS: 1 DIF: Cognitive Level: Application REF: Page 241 OBJ: 7 TOP: Fires KEY: Nursing Process Step: Implementation

6. What should the nurse do when offering a cup of hot coffee to a frail, older adult patient? a. Give the patient a straw b. Dilute the coffee with cold water c. Fill the cup half full d. Offer a bib or an apron

ANS: C Filling the cup half full promotes safety and does not change the flavor of the beverage, nor does it demean the patient as would making him or her wear a bib or apron. PTS: 1 DIF: Cognitive Level: Application REF: Page 230-231 OBJ: 2 TOP: Safety KEY: Nursing Process Step: Implementation

27. The nurse discovers a reddened area over a patient's hip. What should be the nurse's first intervention? a. Cover the area with an occlusive dressing b. Apply mild ointment with a cotton-tipped applicator c. Press the area gently to assess for blanching d. Rub gently to increase circulation

ANS: C If the area is a stage I decubitus ulcer, the area will not blanch. PTS: 1 DIF: Cognitive Level: Application REF: Page 201 OBJ: 5 TOP: Pressure ulcers KEY: Nursing Process Step: Assessment

9. The emergency department nurse admits a victim of poisoning. Who should the nurse call to receive the best assistance for dealing with this victim? a. American Red Cross b. Fire department paramedics c. Poison control center d. Civil defense office

ANS: C The nurse can access the local poison control center for assistance in caring for a victim of poisoning. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 244 OBJ: 8 TOP: Poisoning KEY: Nursing Process Step: Implementation

11. What should a nurse do when encountering a mercury spill? a. Vacuum the spill b. Open interior doors c. Close all outside windows d. Open any outside windows

ANS: D In the event of a mercury spill, interior doors should be closed and outside windows should be opened. The spill should not be vacuumed. PTS: 1 DIF: Cognitive Level: Application REF: Pages 238-239 Box 10-6 OBJ: 9 TOP: Mercury spill KEY: Nursing Process Step: N/A

28. The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse should instruct the patient to remain in the water? a. 5 to 10 minutes b. 10 to 20 minutes c. 20 to 30 minutes d. 30 to 40 minutes

ANS: B A patient should not stay in the water for more than 20 minutes. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 195 Skill 9-1 OBJ: 3 TOP: Hygiene KEY: Nursing Process Step: Implementation

6. A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area? a. Heat from pressure b. Collapse of blood vessels c. Friction from pressure d. Collapse of skin tissue

ANS: B A pressure ulcer occurs when there is sufficient pressure to collapse the blood vessels. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 5 TOP: Pressure ulcers KEY: Nursing Process Step: Evaluation

4. What important safety precaution should the home health nurse teach parents in order to prevent burns to small children? a. Never leave them unattended b. Turn pot handles on stoves away from reach c. Turn hot water on first when filling the bathtub d. Keep side rails up on the crib

ANS: B To protect infants and children from burns, turn the pot handles on stoves away from the child's reach. PTS: 1 DIF: Cognitive Level: Application REF: Page 230 OBJ: 2 TOP: Safety KEY: Nursing Process Step: Implementation

11. What is the site of the most common strain injury acquired by the nurse when working? a. Trapezius muscle group b. Thoracic muscle group c. Lumbar muscle group d. Thigh muscle group

ANS: C The most common back injury is strain of the lumbar muscle group. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 2 TOP: Body mechanics KEY: Nursing Process Step: N/A

8. A disaster situation occurs and involves an explosion in a hospital laundry. What would this be classified as ? a. Active b. External c. Life-threatening d. Internal

ANS: D Internal disaster often threatens the safety of patients and staff. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 244 OBJ: 9 TOP: Disaster KEY: Nursing Process Step: N/A

1. The nurse instructs a nursing assistant to use large muscle groups when lifting. What is the rationale for this instruction? a. Workers' compensation claims will be prevented b. Big muscles work more effectively c. It guarantees no muscle strain d. It distributes workload more evenly

ANS: D Proper body mechanics provide for even distribution of workload. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 161 OBJ: 1 | 2 TOP: Body mechanics KEY: Nursing Process Step: Implementation

15. What profession has the highest workers' compensation claim rates of any occupation or industry? a. Firefighters b. Truck drivers c. Law enforcement d. Nursing personnel

ANS: D Studies of workers' compensation claims show that nursing personnel have the highest claim rates of any occupation or industry. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 2 TOP: Workers' compensation KEY: Nursing Process Step: N/A

5. The nurse is educating a patient on ways to regain the ability to perform ADLs and maintain normal physiological activities. What will the nurse relay as a requirement? a. Strength b. Wellness c. Alertness d. Mobility

ANS: D The purpose of mobility is completing ADLs and maintaining physiological activities. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 166 OBJ: 4 TOP: Mobility KEY: Nursing Process Step: Assessment

37. To prevent skin breakdown in a wheelchair-bound patient, the nurse teaches the patient to shift the patient's weight every minutes.

ANS: 15 fifteen People who are wheelchair-bound should shift their weight by pushing on the arms of their chair every 15 minutes to prevent skin breakdown. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 202 Box 9-5 OBJ: 5 TOP: Skin breakdown KEY: Nursing Process Step: Implementation

12. When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take? (Select all that apply.) a. Walk on the patient's right side b. Keep the patient away from heavy furniture c. Hold the patient's arm securely d. Keep the leg nearest the patient behind the patient's knee e. Use a gait belt

ANS: D, E Ambulating with a person who has an identified weakness requires that the nurse walk on the same side as the weakness, slightly behind the patient, with the nurse's near leg behind the patient's knee. The nurse should use a gait belt and hold the patient at the waist and the gait belt. Furniture can be used as support. PTS: 1 DIF: Cognitive Level: Application REF: Page 230 OBJ: 3 TOP: Ambulating KEY: Nursing Process Step: Implementation

14. When must the nurse remember to use an electric razor when shaving a patient? a. When a bleeding tendency is present b. When there is a risk for suicide c. When the facial hair is fine d. When speed is essential

ANS: A A patient with a bleeding disorder should use an electric razor. PTS: 1 DIF: Cognitive Level: Application REF: Page 207 OBJ: 6 TOP: Shaving KEY: Nursing Process Step: Implementation

16. A nurse instructs a nursing assistant about moving older adult patients in bed. When should the nurse intervene when observing the nursing assistant perform a return demonstration? a. The nursing assistant is using simple language. b. The nursing assistant is avoiding jerky movements. c. The nursing assistant is avoiding sudden movements. d. The nursing assistant is pulling the patient across bed linens.

ANS: D The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements. PTS: 1 DIF: Cognitive Level: Application REF: Page 174 Skill 8-3 OBJ: 10 | 11 TOP: Moving patients KEY: Nursing Process Step: Implementation

25. Place the nursing activities in priority order for the preparation of a patient to ambulate. Put a comma and space between each answer choice (A, B, C, D, etc.). a. Dangle the patient at the side of the bed b. Apply a gait belt c. Assist the patient to stand d. Inform the patient of activity e. Roll up the head of the bed

ANS: D, E, A, B, C The order that is most organized is inform, roll up head of bed, dangle, apply belt, and assist to stand. PTS: 1 DIF: Cognitive Level: Application REF: Page 167 box 8-2 OBJ: 6 TOP: Preparation to ambulate KEY: Nursing Process Step: Implementation

15. is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda.

ANS: Terrorism Terrorism is a violent or dangerous act used to intimidate or coerce a person or government to further a political or social agenda. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 245 OBJ: 9 TOP: Terrorism KEY: Nursing Process Step: N/A

35. The nurse avoids dragging the patient across the bed linen to decrease the potential risk of skin injury by _.

ANS: friction Dragging the patient across bed linen rather than lifting can cause skin damage from friction. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 201-202 OBJ: 5 | 9 TOP: Friction KEY: Nursing Process Step: Implementation

22. When a fall occurs, the nurse should document the incident and initiate a(n) report.

ANS: incident The nurse must initiate an incident report describing the events of a patient's fall. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 167 Box 8-2 OBJ: 6 TOP: Incident report KEY: Nursing Process Step: Implementation

10. A nurse instructs a nursing assistant about the proper use of a gait belt and is observing a return demonstration. What action by the nursing assistant should cause the nurse to intervene? a. Nursing assistant is walking on the patient's strong side b. Nursing assistant is walking to the side of the patient c. Nursing assistant is securing the gait belt securely around the patient's waist d. Nursing assistant is grasping the handles of the gait belt while the patient ambulates

ANS: A A gait belt should be securely applied around the patient's waist. It has handles attached for the nurse to grasp while the patient ambulates. The nurse should walk on the patient's weaker side so that assistance may be given if the patient starts to fall. PTS: 1 DIF: Cognitive Level: Application REF: Pages 230, 234-235 Skill 10-1 OBJ: 4 TOP: Gait belt KEY: Nursing Process Step: N/A

13. What is considered to be the minimum number of hours of daily activity necessary to prevent the negative consequences of immobility? a. 2 hours b. 4 hours c. 6 hours d. 8 hours

ANS: A The amount of exercise required to prevent physical disuse syndrome is 2 hours in 24 hours. PTS: 1 DIF: Cognitive Level: Knowledge REF: Pages 167 Box 8-2 OBJ: 6 TOP: Immobility KEY: Nursing Process Step: Implementation

33. Which guideline should be followed when giving a backrub? a. Observing the skin for abnormalities b. Massaging for at least 10 minutes c. Following massage with a brisk alcohol rub d. Conversing with patient continually throughout the backrub e. Using alcohol-based lotion for disinfection

ANS: A The backrub should last for about 3 to 5 minutes, giving the nurse an opportunity to observe for skin abnormalities. Conversation should be kept to a minimum to enhance relaxation. Alcohol either as a rub or used as disinfectant is drying to the skin. PTS: 1 DIF: Cognitive Level: Application REF: Page 199 Skill 9-1 OBJ: 7 TOP: Backrub KEY: Nursing Process Step: Implementation

22. How should the nurse cleanse the meatal opening when performing male perineal care? a. From the meatus outward b. With an alcohol swab c. In a circular motion d. With a cotton-tipped applicator

ANS: A The nurse should cleanse the meatal opening from the meatus outward. PTS: 1 DIF: Cognitive Level: Application REF: Page 212 Skill 9-4 OBJ: 8 TOP: Perineal care KEY: Nursing Process Step: Implementation

4. What should the water temperature be when preparing a tepid bath for a patient? a. 98.6° F b. 100.2° F c. 104.8° F d. 110.4° F

ANS: A The tepid bath is taken in water that is 98.6° F. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 191 OBJ: 4 TOP: Tepid bath KEY: Nursing Process Step: Implementation

14. A long-term care facility is committing to a restraint-free environment. What will the health care workers implement to encourage this environment? (Select all that apply.) a. Frequent orientation to surroundings b. Explain all procedures and treatments c. Discourage visitors d. Maintain toileting routines e. Minimize exercise and ambulation

ANS: A, B, D To encourage a restraint-free environment health care workers should provide frequent orientation to surroundings, thoroughly explain all procedures and treatments, and maintain toileting routines. Visitors should be encouraged so they may sit with the residents, and frequent exercise and ambulation also should be encouraged. PTS: 1 DIF: Cognitive Level: Application REF: Page 232 Box 10-3 OBJ: 5 TOP: Restraint-free environment KEY: Nursing Process Step: Assessment

13. The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem(s) that may increase because of the use of SRDs? (Select all that apply.) a. Immobility b. Lethargy c. Risk for impaired circulation d. Risk for skin impairment e. Incontinence

ANS: A, C, D, E The use of SRDs increases a patient's immobility, risk for skin impairment, risk for impaired circulation, and incontinence. A SRD would not increase lethargy. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 231 OBJ: 4 TOP: Problems associated with SRDs KEY: Nursing Process Step: Assessment

34. The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task? (Select all that apply.) a. Remove spread and blanket separately b. Place soiled sheet at end of bed c. Place bath blanket over patient on top sheet d. Slide mattress to bottom of bed e. Position patient to far side of bed

ANS: A, C, E When making an occupied bed the nurse will remove the spread and blanket separately. The bath blanket is placed over the patient on the top sheet and the patient is positioned to the far side of the bed. Soiled linen is placed in the laundry bin, not at the end of the bed. The mattress is slid to the top of the bed. PTS: 1 DIF: Cognitive Level: Application REF: Pages 215-216 Skill 9-5 OBJ: 11 TOP: Making occupied bed KEY: Nursing Process Step: Implementation

18. A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.) a. The skin of older adults is more fragile and susceptible to injury. b. Always support older adults under the soft tissue when moving them in bed. c. Weakness and hypertension are common signs and symptoms noted in an older adult on bed rest. d. Aging tends to result in loss of flexibility and joint mobility. e. Older adults sometimes become fearful when hydraulic lifts are used for transfers.

ANS: A, D, E The skin of older adults is more fragile and susceptible to injury. Aging tends to result in the loss of flexibility and joint mobility and older adults sometimes do become fearful with use of hydraulic lifts. Older adults should be supported under the joints when moving in bed. Weakness and hypotension are common signs and symptoms noted in an older adult on bed rest. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 160 OBJ: 3 TOP: Older adult KEY: Nursing Process Step: N/A

11. One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene? a. To improve self-esteem b. To stimulate appetite c. To restore tooth destruction d. To assist with periodontitis

ANS: B A sense of well-being can stimulate appetite. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 204 OBJ: 6 TOP: Oral hygiene KEY: Nursing Process Step: Implementation

12. What implementation might the nurse use to improve safety during a transfer? a. Weighing the patient first b. Using a transfer belt c. Putting shoes on the patient d. Supporting a flaccid arm

ANS: B As a general rule, the nurse should use a transfer belt. PTS: 1 DIF: Cognitive Level: Application REF: Page 182 OBJ: 5 TOP: Body mechanics KEY: Nursing Process Step: Implementation

17. How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter? a. At least once a day b. At least twice a day c. At bedtime d. Each shift

ANS: B Catheter care should be performed at least two times daily. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 207 OBJ: 8 TOP: Catheter care KEY: Nursing Process Step: Implementation

1. The nurse is preparing to bathe a patient. What should the room temperature be set at? a. No warmer than 67° F b. No cooler than 68° F c. No cooler than 70° F d. 75° F or warmer

ANS: B The recommended room temperature is 68° to 74° F. PTS: 1 DIF: Cognitive Level: Application REF: Page 186 OBJ: 1 | 2 | 4 TOP: Patient's environment KEY: Nursing Process Step: Implementation

17. The LPN/LVN assists a patient into the semi-Fowler position per physician order. What would indicate that this patient is in the correct position? a. Patient is leaning over the bedside table b. Head of bed is at a 30-degree angle c. Knee is drawn toward the chest d. Arms are flexed toward the head

ANS: B The semi-Fowler position is when the head of the bed is raised approximately 30 degrees. Orthopneic position is when the patient is leaning over the bedside table. Sims position is when the knee is drawn toward the chest. Arms are not flexed toward the head in the semi-Fowler position. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 164 Skill 8-1 OBJ: 7 TOP: Positioning patients KEY: Nursing Process Step: Implementation

2. The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath? a. 10 to 15 minutes b. 20 to 30 minutes c. 30 to 40 minutes d. 1 hour

ANS: B The sitz bath should last 20 to 30 minutes. PTS: 1 DIF: Cognitive Level: Application REF: Page 191 OBJ: 2 | 3 TOP: Therapeutic baths KEY: Nursing Process Step: Implementation

25. The nurse is providing personal hygiene for a Hindu patient from India. What intervention should the nurse implement? a. Not serve meat b. Shampoo the patient's hair weekly c. Give a daily bath d. Cut nails monthly

ANS: C A daily bath is part of the religious duty of Indian Hindus. PTS: 1 DIF: Cognitive Level: Application REF: Page 186, Cultural Considerations OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Assessment

30. The nurse is caring for a patient experiencing presbycusis. What intervention should the nursing personnel be instructed to implement? a. Speak quickly to the patient b. Speak in loud tones to the patient c. Speak slowly and clearly to the patient d. Tell the patient they must purchase a hearing aid

ANS: C Age-related hearing loss, presbycusis, is a common finding in older adults. It is important to speak slowly and clearly to the patient with presbycusis. Not all patients with this type of hearing loss require a hearing aid. PTS: 1 DIF: Cognitive Level: Application REF: Page 214 OBJ: 6 TOP: Hearing loss KEY: Nursing Process Step: Implementation

18. The nurse is preparing to perform perineal care for the female patient. What is the best method for using a bath blanket to drape the patient? a. Square position b. Long position c. Diamond position d. Rectangular position

ANS: C Drape the patient with a bath blanket in the diamond position. PTS: 1 DIF: Cognitive Level: Application REF: Page 211 Skill 9-4 OBJ: 8 TOP: Perineal care KEY: Nursing Process Step: Implementation

24. What does the nurse recognize is important to consider when using the nursing process to plan hygiene care of the patient? a. Nurse's orders b. Physician's orders c. Patient's preferences d. Outcome goals

ANS: C Individual patients will have individual desires and choices. PTS: 1 DIF: Cognitive Level: Application REF: Page 222 OBJ: 2 TOP: Hygiene KEY: Nursing Process Step: Planning

5. What must the nurse do before applying a safety reminder device (SRD)? a. Get permission from the family b. Assess patient's skin condition c. Get a physician's order d. Explain the SRD to the patient

ANS: C Initially, an order is necessary that specifies the type of SRD and the duration of its application. PTS: 1 DIF: Cognitive Level: Application REF: Page 232, Box 10-4 OBJ: 4 TOP: Safety reminder devices (SRDs) KEY: Nursing Process Step: Planning

21. The nurse must follow the principles of medical asepsis while making a patient's bed, including procedures for handling linens. How should the nurse handle soiled linens? a. Place on the floor b. Fan in the air c. Hold away from the uniform d. Place at the end of the bed

ANS: C Soiled linen should not come into contact with a uniform. PTS: 1 DIF: Cognitive Level: Application REF: Page 215 Skill 9-5 OBJ: 10 TOP: Bed making KEY: Nursing Process Step: Implementation

2. What should the nurse do to reduce the effort of moving a heavy object? a. Bring the feet close together and flex the knees b. Keep the back straight and bend at the waist c. Widen the base of support in the direction of movement d. Broaden the base of support and twist toward the direction of movement

ANS: C The base of support should be broadened in the direction of movement. PTS: 1 DIF: Cognitive Level: Application REF: Page 161 OBJ: 1 | 2 TOP: Body mechanics KEY: Nursing Process Step: Implementation

7. The nurse is caring for an unconscious patient with a risk for skin impairment. How often will the nurse plan to change the position of this patient? a. Every 30 minutes b. Every 60 minutes c. Every 120 minutes d. Every 180 minutes

ANS: C The bedfast patient should have a position change every 2 hours (120 minutes) because skin compromise can occur if there is unrelieved pressure during that amount of time. PTS: 1 DIF: Cognitive Level: Application REF: Page 202 Box 9-5 OBJ: 5 TOP: Pressure ulcers KEY: Nursing Process Step: Implementation

31. A physician orders a patient to be placed in the Trendelenburg position. How will the nurse position the bed? a. On the floor b. Parallel with the floor c. Tilted with the head of the bed down d. Tilted with the foot of the bed down

ANS: C The entire bed is tilted downward with the head of the bed down when placing a patient in the Trendelenburg position. PTS: 1 DIF: Cognitive Level: Application REF: Page 189 Table 9-1 OBJ: 1 TOP: Positioning KEY: Nursing Process Step: Implementation

15. The nurse is bathing a patient with a deep vein thrombosis in the left leg. What modification will the nurse make when attending to the left leg? a. Washing the leg with long, firm strokes and drying with a towel b. Omitting washing the leg at all c. Gently washing the leg and patting dry with a towel d. Applying lotion in long, smooth strokes

ANS: C The lower extremities of people with circulatory disorders are gently washed and patted dry, omitting any stroking or massaging. PTS: 1 DIF: Cognitive Level: Application REF: Page 194 Skill 9-1 OBJ: 3 TOP: Bathing KEY: Nursing Process Step: Implementation

3. What skills should health care workers frequently attend in-services about to ensure that staff has competent skills and risk for falls can be decreased? a. Bathing b. Feeding c. Transferring d. Ambulating

ANS: C The majority of patient falls occur during transfer. PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 229-230 OBJ: 3 TOP: Falls KEY: Nursing Process Step: Implementation

9. How should the nurse assist the patient with moving when pain is anticipated? a. Be supportive b. Apply heat before moving them c. Administer medication before ambulation d. Obtain assistance if the patient is heavy

ANS: C The nurse may want to administer medication before an activity that may be painful. PTS: 1 DIF: Cognitive Level: Application REF: Page 174 Skill 8-3 OBJ: 6 TOP: Body mechanics KEY: Nursing Process Step: Implementation

3. A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement? a. Cover the patient to prevent chilling b. Stay with the patient until the full time for the bath has elapsed c. Remove the patient from the sitz bath and return to bed d. Assess vital signs every 5 minutes during the remainder of the sitz bath

ANS: C The patient may become dizzy during a sitz bath due to dilation of the large vessels in the abdomen. If this occurs, the patient should be removed from the sitz bath and returned to bed. Vital signs should be assessed until they return to normal. PTS: 1 DIF: Cognitive Level: Application REF: Page 191 OBJ: 3 TOP: Sitz bath KEY: Nursing Process Step: Implementation

20. How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula? a. At least every 2 hours b. At least every 6 hours c. At least every 8 hours d. At least every 10 hours

ANS: C When receiving oxygen by a nasal cannula or when a nasogastric tube is in place, the nurse should cleanse the nares every 8 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 214 OBJ: 6 TOP: Nasal care KEY: Nursing Process Step: Implementation

23. The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to: a. 20 degrees. b. 45 degrees. c. 90 degrees. d. 30 degrees.

ANS: D Elimination is facilitated with the head of the bed elevated 30 degrees. PTS: 1 DIF: Cognitive Level: Application REF: Page 221 Skill 9-6 OBJ: 12 TOP: Elimination KEY: Nursing Process Step: Implementation

16. The nurse is providing hand and foot care to a patient and notices the patient has extremely hard nails. Who is the person best prepared to provide nail care for patients with extremely hard nails? a. Physician b. RN c. CNA d. Podiatrist

ANS: D If the patient's nails are extremely hard, a podiatrist should provide care. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 207, 210 Skill 9-3 OBJ: 6 TOP: Foot care KEY: Nursing Process Step: N/A